Website Provider Placement Change Submissions

Help Page - Form Field Descriptions

Note: The fields marked by asterisks MUST be filled out before the form is submitted.

*Name:

• In this field state the name of the person who is making the submission.

*Agency:

• In this field state the name of the agency for which the person making the submission works.

*Contact Number:

• In this field insert the daytime telephone number of the person who is making the submission.

*Email Address:

• In this field insert an email address of the person making the submission.

*Child'is Name:

• In this field enter the first name and last name of the child whose information is changing. A separate submission must be made for each individual child.

*Child'is Date of Birth:

• In this field enter the Date of Birth for the child whose information is changing.

Child'is Social Security Number:

• In this field enter the social security number for the child whose information is changing if known.

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Please Complete the Appropriate Sections:

Date Entered Placement:

• Insert the initial or most recent date of placement with your agency.
• The date a child is moved from one foster home to another within your agency should not be reported here.
• The date of return from a temporary absence should not be reported here.

Date Left Placement:

• Insert the date that the child ended placement with your agency.
• The date that a temporary absence ended should not be entered here.

Rate Begin Date:

• Enter the date the rate is to begin being paid to your agency.

New Rate:

• Enter the rate that is to be paid to your agency by the Sarasota YMCA.

Date of Temporary Absence:

• A temporary absence means the child will return to the placement.
• Enter the date the absence is to begin here.

Date of Return from Temporary Absence:

• Enter the date the child returns to their placement.

Reason for Temporary Absence:

• Click the arrow on the right side of this field to access the drop-down menu.
• Select the reason that applies to the absence being reported.

Bed Hold Request:

• Click the arrow on the right side of this field to access the drop-down menu.
• Select the reason that applies.

Bed Hold Request From:

• Enter the date the bed hold is to begin.

Bed Hold Request To:

• Enter the date the bed hold is to end.

Current Program Name:

• Enter the name of the Program, Foster Home, or Facility that the child is leaving.
• This is used for reporting an in-program change.
• This is used for reporting temporary absence change.
• This can be used for reporting a discharge from a program.

New Program Name:

• Enter the name of the Program, Foster Home, or Facility that the child is entering if known. If not know do not complete.
• This can be used for reporting temporary absence change.

Street Address:

• In this field enter the building number and street name for the new location.
  Example: 5555 33rd St N.

City:

• Enter the name of the city where the new location is.

State:

• Select the State where the new location is from the drop-down menu.

ZIP Code:

• Enter the ZIP Code of the new location.

Phone Number:

• Enter the daytime phone number that can be used to contact the new Foster Home or Facility.

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Additional Comments:

• This field can be used to enter any relevant information that needs to be communicated about this submission, which did not apply to any other field or which needed additional space to accurately explain.
• This includes bed hold request information submitted after normal business hours.